NASA Report: Understanding Columbia's Loss

By Keith Cowing

Posted Tuesday, December 30, 2008

NASA quietly issued a report today titled "Columbia Crew Survival Investigation Report". The report deals with the loss of Space Shuttle Columbia and its crew. Specifically, the report derives important lessons from this accident that need to be considered in the design of future crewed spacecraft.

The report goes into excruciating detail about the events that led up to the breakup of Columbia and the crew's death. Suffice it to say, mercifully, it was very swift: "The Columbia depressurization event occurred so rapidly that the crew members were incapacitated within seconds, before they could configure the suit for full protection from loss of cabin pressure. Although circulatory systems functioned for a brief time, the effects of the depressurization were severe enough that the crew could not have regained consciousness. This event was lethal to the crew."

The crew likely knew that something was wrong but had perhaps a minute, at most,to be aware and to react. According to the report's conclusions and recommendations, "After loss of control at GMT4 13:59:37 and prior to orbiter breakup at GMT 14:00:18, the Columbia cabin pressure was nominal and the crew was capable of conscious actions. The depressurization was due to relatively small cabin breaches above and below the middeck floor and was not a result of a major loss of cabin structural integrity. The crew was not exposed to a cabin fire or thermal injury prior to depressurization, cessation of breathing, and loss of consciousness. The depressurization incapacitated the crew members so rapidly that they were not able to lower their helmet visors."

Of course, learning lessons from fatal accidents is nothing new. Often times, it is all that can be gleaned from loss of a vehicle and its crew - whether they be at sea, in the air, on the ground or in space. Indeed, sometimes virtually nothing can be learned due to the nature of how the accident occurred.

With regard to Columbia, as was the case with the loss of her sister ship and its crew, its loss was eventually attributable to both human and mechanical error albeit with two totally different portions of a Space Shuttle's mission. One happened at the very beginning of a mission, the other at the very end.

Accidents are things to be avoided. However, by the very nature of how we currently send humans into space and return them to Earth, there is a substantial amount of risk involved. Much of that risk has been identified and is manageable. But not all of it. Of course, when you hear this discussion, someone inevitably says that the only way to make these things risk free is not to do them.

Well, we have decided to do these risky things, now haven't we?

Inevitably, when the accidents happen, we need to work our way through them, pause and reflect on what happened, and then press ahead. To be certain there is never a good time for a bad thing to happen. But not to benefit from the information that can arise from studying an accident's cause only serves to remove value from the sacrifice that a crew has made.

According to the report "This investigation was performed with the belief that a comprehensive, respectful investigation could provide knowledge that can protect future crews in the worldwide community of human space flight. Additionally, in the course of the investigation, several areas of research were identified that could improve our understanding of both nominal space flight and future spacecraft accidents."

While we now have a lot of procedural and regulatory hoopla that we are required to go through in modern exploration when accidents occur, post-mission reviews, so to speak, are as old as exploration itself.

One example from history that comes to mind is the Franklin Expedition. In 1845, Sir John Franklin left England with two ships with the task of mapping the yet-to-be-traversed Northwest Passage. Their mission was expected to last several years and they were stocked with provisions for up to three years. Within a few months the expedition vanished and none of the crew were ever seen alive again.

Franklin's wife managed to get the Admiralty to offer a prize to find the lost expedition. Eventually over the next decade or so a dozen ships set off in a series of expeditions to discover what happened to Franklin and his crew. Indeed, more people died and more ships were lost trying to find Franklin and his crew than were lost on the original expedition. Sometimes learning the cause of one accident can be just as dangerous as the accident itself.

Through the course of these expeditions, however, a series of clues were discovered across the Canadian high arctic that eventually led to an answer as to what had happened to the crew. While lives were lost finding answers, clear lessons were learned - all of which contributed to enhanced safety for subsequent expeditions - not just in the arctic but also the antarctic as well. Personnel procedures, means of providing provisions, and even ship design all benefited. And while many advances in exploration technology were achieved without loss of life, knowledge was also derived from mistakes, accidents, and simple bad luck that befell other crews.

Some times, however, the full story takes a long time to emerge. One of the final keys to the puzzle had to await the 20th century.

Three members of Franklin's crew died and were buried on Beechey Island, a small spit of land immediately adjacent to Devon Island. Franklin had chosen this location as the place where his crews waited out the winter of 1845/6. In the 1980s, their frozen bodies were exhumed, thawed, and given a thorough autopsy. From this it was learned that they died of either pneumonia or tuberculosis. They also had extremely high levels of lead in their bodies which was traced back to the lead solder used on their food cans. This may explain many of the other problems that Franklin's crew encountered as they wandered around the arctic - often in ways that defied common sense.

To be certain, food packaging advances progressed in the 19th century without any knowledge of what happened to Franklin's crew. But it does go to show that what seemed to be quite an advance in food storage technology on Franklin's expedition was actually one with hidden dangers - dangers that would only emerge when crews actually lived for prolonged periods of time eating only canned food. Yet risk analysis, so to speak, before their "mission" did not show the possibility of a hazard.

Just like O-rings and foam.

The executive summary of the report closes by placing the report itself into context: "In summary, many findings, conclusions, and recommendations have resulted from this investigation that will be valuable both to spacecraft designers and accident investigators. This report provides the reader an expert level of knowledge regarding the sequence of events that contributed to the loss of Columbia's crew on February 1, 2003 and what can be learned to improve the safety of human space flight for all future crews. It is the team's expectation that readers will approach the report with the respect and integrity that the subject and the crew of Columbia deserve."

At first glance, the timing of the release of this report is curious - and seems to follow a pattern set on 31 December 2007 when NASA PAO snuck out a less than flattering report on air safety data hoping that they could catch the news media off guard. Of course, that backfired on them. The operative word here is "seems".

According to individuals closely familiar with the development of the report, this date was indeed specifically chosen - but not for reasons of trying to slip something under the media's radar. Rather, it was done at the request of the families of Columbia's crew - specifically such that their children would not have to publicly face pressures at school as the report was being released.

Disclaimer: To be certain, I am not an unbiased reporter in this regard. I am on the board of directors of the Challenger Center for Space Science Education and count family members of both Columbia and Challenger crews - as well as astronauts - among my friends. I have built stone memorials in a polar desert to both crews - on Devon Island a few miles from where Franklin's crew were buried. As such, try as I can, I simply cannot ignore my own emotions on this issue. Of course, there are many, many people in my situation.

This report is an unemotional look at the events that led up to the demise of Space Shuttle Columbia and its crew. While much of what went wrong is inherent in the way that Space Shuttles were designed and flown, other things are fixable and should certainly be kept in mind as future spacecraft are built.

But as we read through this engineering document we also need to keep in mind, in the end, that this was a vessel designed to carry people to and from space. This broader issue is, of course, beyond the scope of this document but bears repeating none the less.

I guess all I can add is what I wrote in 2007 on Devon Island "All too often these two shuttle crews are compared for the wrong reasons: what went wrong with their spacecraft and who was to blame. It is this that lingers - and manages to find its way appended to almost every story about NASA wherein some new problem has arisen. What always seems to suffer as a result as we look back is who these people were - what they were doing, why they did it, and what legacy they leave behind for us to utilize - and build upon. Hopefully we will recall that they confronted danger with determination - and that courage can find its way into the minds of future generations."